Information Collection

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

IC 235104 under ICR 201910-0906-004 · OMB 0906-0042.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0042 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
1 01_Updated MCH Survey_AS_English.doc 01_Updated MCH Survey_AS_English.doc	Form and Instruction
2 02_Updated MCH Survey_FSM_English.doc 02_Updated MCH Survey_FSM_English.doc	Form and Instruction
3 03_Updated MCH Survey_Guam_English.doc 03_Updated MCH Survey_Guam_English.doc	Form and Instruction
4 04_Updated MCH Survey_RMI_English.doc 04_Updated MCH Survey_RMI_English.doc	Form and Instruction
5 05_Updated MCH Survey_CNMI_English.doc 05_Updated MCH Survey_CNMI_English.doc	Form and Instruction
6 06_Updated MCH Survey_Palau_English.doc 06_Updated MCH Survey_Palau_English.doc	Form and Instruction
7 07_Updated MCH Survey_PR_English.doc 07_Updated MCH Survey_PR_English.doc	Form and Instruction
8 08_Updated MCH Survey_USVI_English.doc 08_Updated MCH Survey_USVI_English.doc	Form and Instruction
9 09_Updated MCH Survey_American Samoa_Samoan.doc 09_Updated MCH Survey_American Samoa_Samoan.doc	Form and Instruction
10 10_Updated MCH Survey_FSM_Chuukese.doc 10_Updated MCH Survey_FSM_Chuukese.doc	Form and Instruction
11 11_Updated MCH Survey_Guam_Chuukese.doc 11_Updated MCH Survey_Guam_Chuukese.doc	Form and Instruction
12 12_Updated MCH Survey_Guam_Tagalog.doc 12_Updated MCH Survey_Guam_Tagalog.doc	Form and Instruction
13 13_Updated MCH Survey_Palau_Palauan.doc 13_Updated MCH Survey_Palau_Palauan.doc	Form and Instruction
14 14_Updated MCH Survey_Palau_Tagalog.doc 14_Updated MCH Survey_Palau_Tagalog.doc	Form and Instruction
15 15_Updated MCH Survey_PR_Spanish.doc 15_Updated MCH Survey_PR_Spanish.doc	Form and Instruction
16 16_Updated MCH Survey_USVI_Spanish.doc 16_Updated MCH Survey_USVI_Spanish.doc	Form and Instruction
17a 17a_MCH Jurisdictional Survey Eligibility and Consent Sc 17a_MCH Jurisdictional Survey Eligibility and Consent Script_Marshallese.docx	Form and Instruction
17b 17b_MCH Jurisdictional Survey Leave-Behind Consent_Marsh 17b_MCH Jurisdictional Survey Leave-Behind Consent_Marshallese.docx	Form and Instruction
17c 17c_MCH Survey_RMI_Marshallese Aug 2019.doc 17c_MCH Survey_RMI_Marshallese Aug 2019.doc	Form and Instruction
18a 18a_MCH Jurisdictional Survey Eligibility and Cons 18a_MCH Jurisdictional Survey Eligibility and Consent Script_Pohnpeian.docx	Form and Instruction
18b 18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnp 18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian.docx	Form and Instruction
18c 18c_MCH Survey_FSM_Pohnpeian.doc 18c_MCH Survey_FSM_Pohnpeian.doc	Form and Instruction
MCH Survey Eligibility and Consent Script_ENGLISH.docx MCH Survey Eligibility and Consent Script_ENGLISH	IC Document
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx MCH Survey Eligibility and Consent Script_No Inc_ENGLISH	IC Document
MCH Survey Leave-Behind Consent_ENGLISH.docx MCH Survey Leave-Behind Consent_ENGLISH	IC Document
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx MCH Survey Leave-Behind Consent_No Incentive_ENGLISH	IC Document
MCH Survey Eligibility and Consent Script_CHUUKESE.docx MCH Survey Eligibility and Consent Script_CHUUKESE	IC Document
MCH Survey Eligibility and Consent Script_No Inc_PALAUAN.docx MCH Survey Eligibility and Consent Script_No Inc_PALAUAN	IC Document
MCH Survey Eligibility and Consent Script_No Inc_TAGALOG.docx MCH Survey Eligibility and Consent Script_No Inc_TAGALOG	IC Document
MCH Survey Eligibility and Consent Script_SAMOAN.docx MCH Survey Eligibility and Consent Script_SAMOAN	IC Document
MCH Survey Eligibility and Consent Script_SPANISH.docx MCH Survey Eligibility and Consent Script_SPANISH	IC Document
MCH Survey Eligibility and Consent Script_TAGALOG.docx MCH Survey Eligibility and Consent Script_TAGALOG	IC Document
MCH Survey Leave-Behind Consent_CHUUKESE.docx MCH Survey Leave-Behind Consent_CHUUKESE	IC Document
MCH Survey Leave-Behind Consent_No Incentive_PALAUAN.docx MCH Survey Leave-Behind Consent_No Incentive_PALAUAN	IC Document
MCH Survey Leave-Behind Consent_No Incentive_TAGALOG.docx MCH Survey Leave-Behind Consent_No Incentive_TAGALOG	IC Document
MCH Survey Leave-Behind Consent_SAMOAN.docx MCH Survey Leave-Behind Consent_SAMOAN	IC Document
MCH Survey Leave-Behind Consent_SPANISH.docx MCH Survey Leave-Behind Consent_SPANISH	IC Document
MCH Survey Leave-Behind Consent_TAGALOG.docx MCH Survey Leave-Behind Consent_TAGALOG	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	01_Updated MCH Survey_AS_English.doc	01_Updated MCH Survey_AS_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	2	02_Updated MCH Survey_FSM_English.doc	02_Updated MCH Survey_FSM_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3	03_Updated MCH Survey_Guam_English.doc	03_Updated MCH Survey_Guam_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4	04_Updated MCH Survey_RMI_English.doc	04_Updated MCH Survey_RMI_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	5	05_Updated MCH Survey_CNMI_English.doc	05_Updated MCH Survey_CNMI_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	6	06_Updated MCH Survey_Palau_English.doc	06_Updated MCH Survey_Palau_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	7	07_Updated MCH Survey_PR_English.doc	07_Updated MCH Survey_PR_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	8	08_Updated MCH Survey_USVI_English.doc	08_Updated MCH Survey_USVI_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	9	09_Updated MCH Survey_American Samoa_Samoan.doc	09_Updated MCH Survey_American Samoa_Samoan.doc	Yes	Yes	Fillable Fileable
Form and Instruction	10	10_Updated MCH Survey_FSM_Chuukese.doc	10_Updated MCH Survey_FSM_Chuukese.doc	Yes	Yes	Fillable Fileable
Form and Instruction	11	11_Updated MCH Survey_Guam_Chuukese.doc	11_Updated MCH Survey_Guam_Chuukese.doc	Yes	Yes	Fillable Fileable
Form and Instruction	12	12_Updated MCH Survey_Guam_Tagalog.doc	12_Updated MCH Survey_Guam_Tagalog.doc	Yes	Yes	Fillable Fileable
Form and Instruction	13	13_Updated MCH Survey_Palau_Palauan.doc	13_Updated MCH Survey_Palau_Palauan.doc	Yes	Yes	Fillable Fileable
Form and Instruction	14	14_Updated MCH Survey_Palau_Tagalog.doc	14_Updated MCH Survey_Palau_Tagalog.doc	Yes	Yes	Fillable Fileable
Form and Instruction	15	15_Updated MCH Survey_PR_Spanish.doc	15_Updated MCH Survey_PR_Spanish.doc	Yes	Yes	Fillable Fileable
Form and Instruction	16	16_Updated MCH Survey_USVI_Spanish.doc	16_Updated MCH Survey_USVI_Spanish.doc	Yes	Yes	Fillable Fileable
Form and Instruction	17a	17a_MCH Jurisdictional Survey Eligibility and Consent Script_Marshallese.docx	17a_MCH Jurisdictional Survey Eligibility and Consent Script_Marshallese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	17b	17b_MCH Jurisdictional Survey Leave-Behind Consent_Marshallese.docx	17b_MCH Jurisdictional Survey Leave-Behind Consent_Marshallese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	17c	17c_MCH Survey_RMI_Marshallese Aug 2019.doc	17c_MCH Survey_RMI_Marshallese Aug 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	18a	18a_MCH Jurisdictional Survey Eligibility and Cons	18a_MCH Jurisdictional Survey Eligibility and Consent Script_Pohnpeian.docx	Yes	Yes	Fillable Fileable
Form and Instruction	18b	18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian.docx	18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian.docx	Yes	Yes	Fillable Fileable
Form and Instruction	18c	18c_MCH Survey_FSM_Pohnpeian.doc	18c_MCH Survey_FSM_Pohnpeian.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,955

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,955	5,955
Annual IC Time Burden (Hours)	1,605	1,605
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.